Prevention, control and cure of respiratory diseases and

promotion of respiratory health must be a top priority in

global decision-making in the health sector. These goals
are achievable, and the control, prevention and cure of
respiratory diseases are among the most important cost-
effective health interventions available. In this report, the
Forum of International Respiratory Societies (FIRS) asserts
that alleviating the burden of respiratory disease should be a
leading strategy of the Sustainable Development Goals and
a requirement for nations to achieve.

The Global Impact of

Respiratory Disease
Second Edition
Forum of International Respiratory Societies
The Global Impact of
Respiratory Disease
– Second Edition

Forum of International Respiratory Societies

The Global Impact of Respiratory Disease – Second Edition
Forum of International Respiratory Societies

Print ISBN: 9781849840873; e-ISBN: 9781849840880

Cite this publication as: Forum of International Respiratory Societies. The Global Impact of
Respiratory Disease – Second Edition. Sheffield, European Respiratory Society, 2017.

Image credits

Front cover. Mother with her child hospitalised for respiratory disease in South Africa.
© Dr Rudzani Muloiwa.
Page 9. The air we breathe. © 2012 SLR club, Courtesy of Photoshare.
Pages 10/11. A man in India consults a physician after a potential infection with tuberculosis.
© 2011 Benoit Matsha-Carpentier/IFRC, Courtesy of Photoshare.
Page 13. Lung testing as part of the Healthy Lungs for Life campaign at the European
Respiratory Society 2016 Congress in London. © Jared Pepallo.
Page 15. Family members in Zambia listen as a doctor shows them how to manage their
daughter’s asthma. © 2012 Malcolm Spence/On Call Africa, Courtesy of Photoshare.
Page 17. A young boy takes a breathing treatment after his first bout with pneumonia in
southeast New Mexico, USA. © 2010 Amber Willier, Courtesy of Photoshare.
Pages 18/19. A nurse vaccinates a four-month-old baby in the Nueva Segovia state of
Nicaragua on the northern border with Honduras. © 2008 Adrian Brooks, Courtesy of
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machine. © 2011 David Snyder, Courtesy of Photoshare.
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Pages 22/23. A healthcare worker administering a dose of Bacillus Calmette–Guérin (BCG)
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 Contents
Foreword 5
Executive summary 6
Introduction 7
The Big Five 10
COPD 12
Asthma 14
Acute lower respiratory tract infection 16
Tuberculosis 20
Lung cancer 24
Other important respiratory conditions and concerns 26
What can be done to combat respiratory disease? 28
Summary 32
Recommendations 33
References 34
Acknowledgements 38
About FIRS 39
FIRS member societies 40

The World Health Organization (WHO) launched
the Global Alliance Against Respiratory Diseases
(GARD) in 2006 with the aim to bring together the
combined knowledge of national and international
organisations, institutions and agencies to improve
the lives of more than one billion people affected
by chronic and acute respiratory diseases.
The 2030 Sustainable Development Agenda was
adopted by world leaders in 2015 at a historic
UN Summit in New York and came into force on
January 1, 2016. The very ambitious agenda
is a plan of action to achieve 17 Sustainable
Development Goals (SDGs) and 169 targets by
the year 2030, which include the economic, social
and environmental dimensions of sustainable
development.
SDG goal 3: Ensure healthy lives and promote
well-being for all at all ages is one of the most
important goals and needs to receive special
attention by governments and all stakeholders.
Improved health will bring people out of poverty
and contribute substantially to sustainable
development. A lot of progress has been made in
increasing life expectancy and reducing the burden
of many diseases such as polio, maternal mortality
and the spread of HIV/AIDS. However, many
challenges remain to be addressed if countries are
to achieve SDG 3.
Noncommunicable diseases (NCDs), including
cardiovascular diseases, cancers, chronic
respiratory diseases and diabetes, are the biggest
killers today. One of the very ambitious goals is to
reduce mortality from NCDs by 30% by the year
2030. The WHO Global Action Plan on NCDs has
recognised the strong interaction between NCDs
and infectious diseases, including tuberculosis in
particular in low- and middle-income countries and
is asking to explore opportunities to improve the
detection and treatment of co-morbidities within
health services.
Forum of International Respiratory Societies
Foreword
This Forum of International Respiratory Societies
(FIRS) report highlights these comorbidities
but also addresses forcefully the link between
respiratory diseases and the environment and
emphasises the importance of prevention, which
should start before birth. Tobacco smoke, indoor
air pollution from burning fuels, air pollution from
traffic and industrial sources are highlighted as
contributing to most respiratory conditions.
We are living in a world with so many competing
public health priorities and chronic respiratory
diseases have not received the attention they
would really deserve. Better advocacy for lung
health is badly needed to convince policy
makers, governments, donors, nongovernmental
organisations and civil society to scale up
prevention and control programmes in all countries,
in particular in low- and middle-income countries.
FIRS is contributing with this excellent report to
put lung health high on the global agenda.
I would like to congratulate FIRS for having
prepared this very impressive comprehensive
report on the global impact of tuberculosis, asthma,
COPD, acute lower respiratory tract infections and
lung cancer. It summarises in a very concise way
the burden of disease and outlines the possibilities
to improve prevention and treatment programmes
and outlines the scope for control and elimination
of these conditions.
The report will no doubt increase awareness
about the major lung diseases globally and
lead to accelerated action among all interested
stakeholders.
Professor Nikolai Khaltaev
Chair of GARD
5
 Executive summary
We take our breathing and our respiratory
health for granted, but the lung is a vital organ
that is vulnerable to airborne infection and
injury. Respiratory diseases are leading causes
of death and disability in the world. About 65
million people suffer from chronic obstructive
pulmonary disease (COPD) and 3 million die
from it each year, making it the third leading
cause of death worldwide. About 334 million
people suffer from asthma, the most common
chronic disease of childhood affecting 14% of
all children globally. Pneumonia kills millions
of people annually and is a leading cause of
death among children under 5 years old. Over
10 million people develop tuberculosis (TB)
and 1.4 million die from it each year, making
it the most common lethal infectious disease.
Lung cancer kills 1.6 million people each year
and is the most deadly cancer. Globally, 4
million people die prematurely from chronic
respiratory disease. At least 2 billion people are
exposed to indoor toxic smoke, 1 billion inhale
outdoor pollutant air and 1 billion are exposed
to tobacco smoke. The truth is that many of us
are naïve to these stark realities.
Fortunately, most respiratory diseases are
preventable by improving the quality of the air.
Common sources of unhealthy air are tobacco
smoke, indoor and outdoor air pollution, and
6 Forum of International Respiratory Societies
air containing microbes, toxic particles, fumes
or allergens. Reducing tobacco consumption
is the most important first step. Controlling
unhealthy air in the workplace can prevent
occupational lung disease. Strengthening
immunisation programmes can prevent many
types of pneumonia. Improving respiratory
health also entails strengthening healthcare
systems, using established guidelines for health
promotion and disease prevention, training
medical personnel, research, and educating
the populace.
Prevention, control and cure of these diseases
and promotion of respiratory health must be
a top priority in global decision-making in the
health sector. These goals are achievable, and
the control, prevention and cure of respiratory
diseases are among the most important cost-
effective health interventions available. The
Forum of International Respiratory Societies
(FIRS) asserts that alleviating the burden of
respiratory disease should be a leading strategy
of the Sustainable Development Goals and a
requirement for nations to achieve.
The purpose of this report is to call attention
to the importance of respiratory health in the
world and to raise it to be a top priority in
global decision-making.
 Introduction
The lung is the internal organ most vulnerable
to infection and injury from the external
environment because of its constant exposure
to particles, chemicals and infectious
organisms in ambient air. Globally, at least 2
billion people are exposed to the toxic smoke
of biomass fuel, typically burned inefficiently in
poorly ventilated indoor stoves or fireplaces.
One billion people inhale polluted outdoor air,
and 1 billion are exposed to tobacco smoke.
Although respiratory impairment causes
disability and death in all regions of the world
and in all social classes, poverty, crowding,
environmental exposures and generally poor
living conditions increase vulnerability to this
large group of disorders.
Respiratory diseases impose an immense
worldwide health burden. Five of these
diseases are among most common causes of
severe illness and death worldwide [1].
• An estimated 65 million people have
moderate to severe chronic obstructive
pulmonary disease (COPD), from
which about 3 million die each year,
making it the third leading cause of
death worldwide – and the numbers are
increasing [2, 3].
• About 334 million people suffer from
asthma [4], which is the most common
chronic disease of childhood, affecting
14% of children globally. The prevalence
of asthma in children is rising [5].
• For decades, acute lower respiratory
tract infections have been among
the top three causes of death and
disability among both children and
adults. Although the burden is difficult
Forum of International Respiratory Societies
to quantify, it is estimated that lower
respiratory tract infection causes nearly 4
million deaths annually and is a leading
cause of death among children under
5 years old [6]. Moreover, acute lower
respiratory tract infections in children
predispose for chronic respiratory
diseases later in life. Respiratory tract
infections caused by influenza kill
between 250,000 and 500,000 people
and cost between US$71 and 167 billion
annually [7].
• In 2015, 10.4 million people developed
tuberculosis (TB) and 1.4 million people
died from it [8].
• The most common lethal neoplasm in
the world is lung cancer, which kills 1.6
million people each year [9]; and the
numbers are growing.
In addition to these five, there are several
respiratory disorders whose burden is great
but less well quantified.
• More than 100 million people suffer from
sleep-disordered breathing [2].
• Millions live with pulmonary
hypertension [2].
• More than 50 million people struggle
with occupational lung diseases.
Respiratory diseases account for more than
10% of all disability-adjusted life-years
(DALYs), a metric that estimates the amount
of active and productive life lost due to a
condition. Respiratory diseases are second
only to cardiovascular diseases (including
stroke) [10].
7
 Respiratory diseases make up five of the 30
most common causes of death: COPD is
third; lower respiratory tract infection is fourth;
tracheal, bronchial and lung cancer is sixth;
TB is twelfth; and asthma is twenty-eighth
[1]. Altogether, more than 1 billion people
suffer from either acute or chronic respiratory
conditions. The stark reality is that, each
year, 4 million people die prematurely from
chronic respiratory disease [11]. Infants and
young children are particularly susceptible. A
total of 9 million children under 5 years old
die annually, and pneumonia is the world’s
leading killer of these children [1].
Even more distressing is the enormous
suffering that living with these illnesses cause.
Those who are most disadvantaged suffer most
8 Forum of International Respiratory Societies
from poor health. With this awareness, the
United Nations (UN) created the Sustainable
Development Goals (SDGs) in 2016 [12] to
raise living standards globally. The Forum
of International Respiratory Societies (FIRS)
is part of a global effort to call for action
to address the huge burden of respiratory
diseases. FIRS asserts that alleviating this
burden should be a leading strategy of
the Sustainable Development Goals and a
requirement for nations to achieve these
goals. FIRS has previously published a report
[13] to call for improvements in healthcare
policies, systems and care delivery, as well as
providing direction for future research, and
this report aims to provide an update on what
has happened in the intervening years.
Forum of International Respiratory Societies 9
10 Forum of International Respiratory Societies
 THE BIG FIVE
COPD, asthma, acute lower respiratory tract infections,
TB and lung cancer are among most common causes of
severe illness and death worldwide.

Scope of the disease
COPD affects more than 200 million people
in the world [2], 65 million of whom have
moderate or severe airway disease [2], and
most studies show it is underdiagnosed by 72
to 93% [14]. This is higher than reported for
hypertension, hypercholesterolaemia and many
other important disorders. Misdiagnosis is also
common [15]. The high prevalence and severity
of illness make its economic cost high. The
direct cost of COPD is 6% of total healthcare
spending (€38.6 billion annually) in the European
Union and accounts for 56% of the total cost of
treating respiratory diseases [16].
The most important factor leading to the
development of COPD is tobacco smoking.
Tobacco smoke causes destruction of lung
tissue (emphysema) and obstruction of the
small airways with inflammation and mucus
(chronic bronchitis), leading to the cardinal
symptoms of COPD, namely shortness of
breath and cough. Indoor and outdoor
air pollution, inhaled tobacco smoke and
occupational dust, genetic syndromes (such
as 1-antitrypsin deficiency), childhood
pneumonia and other diseases that involve the
airways (such as chronic asthma and TB) are
also factors contributing to the development
of COPD [17].
Prevention
Discouraging individuals from starting to
smoke tobacco and encouraging smokers
to reduce and quit smoking are the first and
most important priorities in preventing COPD.
Chimney cook stoves and other devices that
decrease indoor smoke exposure lessen the
12 Forum of International Respiratory Societies
COPD
risk of respiratory infections in children and
potentially the incidence of COPD in non-
smokers, particularly in women. Childhood
vaccines and prompt recognition and
treatment of lower respiratory tract infections
will minimise the airway injury that predisposes
to COPD in adulthood. COPD may begin in
childhood. Management of childhood asthma,
controlling occupational exposure to dust
and fumes, and other environmental controls
could have substantial benefits in reducing
the burden of COPD.
Widespread population screening for COPD
in asymptomatic adults is not recommended
[18], but performing spirometry in populations
with risk factors and respiratory symptoms is
[19]. For example, clinicians should pursue a
diagnosis for people exposed to smoke from
cigarettes and biomass fuels, occupational
dusts and chemicals, and having a family
history of 1-antitrypsin deficiency.
Treatment
Spirometry is required to establish a clinical
diagnosis of COPD and is the first step
in treatment. Using spirometry avoids
misdiagnosis and assists in evaluating
the severity of the airflow limitation.
Identification and reduction of exposure to
risk factors are essential to prevent and treat
the disease. Avoiding air pollution and other
precipitating factors is also important. All
individuals who smoke should be identified
and provided with assistance to enable them
to quit. Vaccination against seasonal influenza
can reduce the risk of severe exacerbations
triggered by influenza [20].
Along with removal of respiratory irritants or
triggers and early treatment of respiratory
infections, inhaled bronchodilators are the
basic medicines that help these patients.
Treatment with long-acting bronchodilators,
together with inhaled corticosteroids and other
pharmacological and non-pharmacological
agents, can help patients with frequent
exacerbations and severe airflow obstruction.
Patients with low blood oxygen levels may
require supplemental oxygen. Long-term
oxygen therapy can increase survival and
improve the quality of life in patients with very
low oxygen levels. Maintaining physical fitness
and activity is important because difficulty
breathing may lead to a decreased activity
and subsequent deconditioning. Therefore,
exercise-based pulmonary rehabilitation is
important for many people with COPD [21].
Treating coexisting illnesses can extend the
life of many people.
Clinical strategies are available that outline
the appropriate management of people with
COPD [22]. Despite the availability of clinical
practice guidelines, several studies have
shown that COPD is undertreated in its early
as well as advanced stages.
Forum of International Respiratory Societies
Control and elimination
The key element of reducing and controlling
COPD is abolishing tobacco use. This is best
addressed through political and public health
initiatives. Public health and societal efforts are
needed to reduce indoor smoke exposure and
other COPD risk factors, and to develop cost-
effective management protocols for COPD,
especially in low-income settings. Age-specific
mortality rates from COPD are now declining,
but the ageing world population makes this a
huge problem for decades to come. Research
should lead to better understanding of how
risk factors and comorbidities interact to affect
the severity of disease, and which other factors
cause COPD in smokers and non-smokers.
Other important research questions include
how best to identify and treat mild COPD,
and how to manage COPD in the context
of concomitant conditions, such as sleep
apnoea, cardiovascular disease, depression,
osteoporosis, diabetes, lung cancer, ageing
and frailty. This research is needed to build
management plans on a sound knowledge
base.
13

Scope of the disease
Asthma afflicts up to 334 million people
worldwide [4] and its incidence has been
increasing for the past three decades [5]. It
affects all ages, races and ethnicities, though
wide variation exists in different countries and
in different groups within the same country.
It is the most common chronic disease in
children and is more severe in children
living in non-affluent countries [23]. In these
settings, underdiagnosis and under-treatment
are common, and effective medicines may
not be available or affordable. The burden of
asthma is high [4, 10]. It is one of the most
frequent reasons for preventable hospital
admissions among children in high-income
countries, but less information is available
from low- and middle-income countries [4].
In some studies, asthma accounts for more
than 30% of all paediatric hospitalisations
and nearly 12% of readmissions within 180
days of discharge [24]. It is not widely realised
that asthma causes about 489,000 deaths per
year or more than 1,300 deaths per day [1].
Recent evidence indicates that children with
asthma may have abnormal lung growth and
are at risk for developing lifelong respiratory
compromise and COPD [25].
The causes of the increase in global prevalence
of asthma are not well understood. Genetic
predisposition, exposure to environmental
allergens, indoor and outdoor air pollution,
lower respiratory tract infection early in life,
airway microbiome makeup, dietary factors
and abnormal immunological responses may
promote the development of asthma. The
timing and level of exposure to allergens,
14 Forum of International Respiratory Societies
Asthma
infection or irritants may be major factors
leading to the development of disease. Early
viral infections and passive tobacco smoke
exposure have been associated with the
development of asthma in young children.
Airborne allergens and irritants associated
with asthma occur in the workplace and
can lead to chronic and debilitating disease
among workers if the exposure persists.
Prevention
The cause of most asthma is unknown and
there is no effective strategy for primary
prevention. However, potentially modifiable
risk factors for development of asthma include
smoking during pregnancy and use of broad-
spectrum antibiotics in the first year of life.
Asthmatics who smoke have a more rapid
decline in lung function than lifelong non-
smokers. Avoiding smoking during pregnancy
and avoidance of passive smoke exposure after
birth can reduce asthma severity in children.
Epidemiological interventions involving work-
related asthma show that, in adulthood, early
removal of allergens or irritants may lead to
better control of the disease, although the
burden and cost of the intervention need
to be taken into account. There is little
evidence for effective single-strategy indoor
allergen avoidance interventions in adults
outside the occupational context, except for
remediation of dampness and mould. The
use of maintenance controller medication can
effectively prevent intercurrent asthma attacks
with a resultant decline in lung function, and
has been clearly shown to reduce mortality
and hospitalisations [4].
Treatment
Making a correct diagnosis is essential for
treatment, and improving access to spirometry
will help to reduce misdiagnosis. Asthma
is generally a lifelong disease that is not
curable, but treatment with quality-assured
essential asthma medicines can effectively
control the disease. Inhaled corticosteroids
are the cornerstone of effective asthma
control. When used appropriately, that is,
taken regularly with correct technique and a
spacer or other device to assure inhalation,
these medicines can decrease the severity and
frequency of symptoms of asthma. They also
reduce the need for reliever inhalers (rapid-
acting bronchodilators) and the frequency of
severe episodes (“exacerbations”) requiring
urgent medical care, emergency room
visits, hospitalisations and death. Inhaled
bronchodilators are important for providing
quick relief from asthma symptoms.
Unfortunately, many people suffering from
asthma do not have access to effective
quality-assured asthma medicines. Even
though inhaled corticosteroids and inhaled
bronchodilators are on the essential drug list
of the World Health Organization (WHO), they
are either unavailable or unaffordable in many
settings [4, 26].
Lack of availability of medicines is not the only
reason people with asthma do not receive
effective care. Widespread misconceptions
about the nature of the disease and its
treatment often prevent people from
Forum of International Respiratory Societies
using appropriate treatments. Educational
campaigns to encourage regular use of
inhaled corticosteroids for control, avoidance
of exposures that trigger asthma attacks and
provision of written asthma action plans, so
that the patient can respond to worsening
asthma, are important parts of effective
asthma control programmes.
Control and elimination
Additional research is needed to better
understand the earliest origins of asthma,
the causes of exacerbations and reasons
for its rising prevalence in many countries
[5]. Elimination is a distant vision. The
International Study of Asthma and Allergies
in Childhood (ISAAC) has provided insights
into the disease and facilitated standardised
research on asthma in children that has
helped to define the prevalence, trends
and determinants of asthma and allergies
worldwide. This work and other research
findings are being incorporated into evidence-
based strategies for the management of
asthma. Dissemination and implementation
of these strategies will improve asthma
control. Making quality-assured inhaled
corticosteroids, bronchodilators and spacer
devices widely available at an affordable price,
and educating people with asthma about the
disease and its management are key steps to
improve outcomes for people with asthma.
Strategies to reduce indoor air pollution,
smoke exposure and respiratory infections will
improve asthma control and reduce the need
for healthcare utilisation.
15
 Acute lower
respiratory tract infection
Scope of the disease
Lower respiratory tract infection and
pneumonia are two of the leading causes
of death, accounting for more than 4
million fatalities annually. It is a particularly
important cause of death in low- and middle-
income countries [27]. Lower respiratory
tract infection kills more people than human
immunodeficiency virus (HIV), TB and malaria
combined [6]. It is the leading cause of death
in children under 5 years of age outside
the neonatal period [6]. Pneumonia killed
920,136 children aged under 5 years in 2015,
accounting for 15% of the deaths in this age
group [28]. It is also the second leading cause
of years of life lost due to premature mortality
[27] and one of the most frequent reasons for
hospitalisation.
Risk factors for pneumonia include being very
young or elderly, crowded living conditions,
malnutrition, HIV infection, lack of breast-
feeding in infants, lack of immunisation,
chronic health conditions and exposure to
tobacco smoke or indoor air pollutants.
Streptococcus pneumoniae remains the most
frequent bacterial cause of pneumonia and
killed 393,000 children aged under 5 years
in 2015 [1]. HIV infection increases the risk of
pneumonia caused by this organism twenty-
fold, although the incidence of severe disease
has declined with better immunisation and
the use of antiretroviral therapy. Pneumonia
can also lead to chronic respiratory diseases,
such as bronchiectasis.
Viral respiratory infections can occur in
epidemics and spread rapidly within
16 Forum of International Respiratory Societies
communities across the globe. Every year,
influenza leads to respiratory tract infections in
5–15% of the population and severe illness in
3–5 million people [29]. Respiratory syncytial
virus (RSV) is the most common cause of
acute respiratory infection in children, causing
almost 34 million episodes annually. More than
90% of deaths from RSV respiratory infection
in children occur in low- and middle-income
countries [30].
Ominously, new respiratory pathogens are
emerging. In 2003, severe acute respiratory
syndrome (SARS), caused by a previously
unrecognised coronavirus, rapidly spread
throughout the world. Its lethality mobilised
international efforts that rapidly identified
the cause and the method of spread.
Stringent infection control measures reduced
its spread effectively and no further cases
were identified [31]. The risk of another
global epidemic caused by a new virus or a
mutation in a known virus has encouraged
health officials and researchers to find ways
to limit or prevent such a catastrophe. These
events can stress national healthcare systems,
leading to widespread disaster. Respiratory
viruses can spread quickly because of the
ease of transmission, as has been seen in past
influenza pandemics.
Prevention
Childhood respiratory disease can be
prevented or ameliorated by several measures:
improving childhood nutrition and promoting
breastfeeding (both of which improve
immune status); ensuring comprehensive
immunisation; improving living conditions to
prevent crowding; avoiding tobacco smoke
exposure from the time of conception through
childhood; reducing indoor air pollution;
treating or preventing HIV infection; giving
prophylactic antibiotics in immunosuppressed
children; and preventing mother-to-child
HIV transmission. Several of these measures
are also appropriate for respiratory disease
prevention in adults.
Vaccination is one of the greatest achievements
of modern public health, yet many children
are unimmunised against preventable
infections particularly in low- and middle-
income countries. Countries with the lowest
immunisation rates account for more than
two-thirds of the vaccine-preventable disease
burden and have the highest childhood
mortality.
Treatment
The success of prevention or treatment of
many respiratory infections is dependent
on the quality of the healthcare system.
Most bacterial infections are treatable with
antibiotics and most viral infections are self-
limited. Yet millions of people still die of
pneumonia. The failure to prevent these deaths
often results from lack of access to healthcare
and effective preventive interventions
including immunisation. Comorbidities, such
as HIV infection and malnutrition, and lack
of awareness and education may lead to
advanced disease before the affected people
seek medical attention. Late presentation
leads to greater treatment failure.
The most effective way to manage
these diseases is through standard case
management. Case management is defined
as “a collaborative process of assessment,
planning, facilitation, care coordination,
evaluation, and advocacy for options and
services to meet an individual’s and a family’s
comprehensive health needs through
communication and available resources to
promote quality cost-effective outcomes” [29].
For childhood pneumonia, a standard
approach to diagnosis and treatment
has been developed by the WHO in the
Integrated Management of Childhood Illness
programme. The cornerstone of pneumonia
management is the appropriate diagnosis
and use of antibiotics. Supplemental oxygen
is essential for effective treatment of severe
Forum of International Respiratory Societies
pneumonia, although its delivery is not
available in many low- or middle-income
countries. Enhancing availability of oxygen
delivery systems in these areas must be a
global priority. In the management of adults
with pneumonia, several national guidelines
have been developed and many studies
have documented that adherence to these
guidelines is associated with better patient
outcomes.
Control and elimination
Vaccines are essential for the control and
elimination of many of these childhood
diseases. The development of new conjugate
vaccines against Streptococcus pneumoniae
(pneumococcus) and Haemophilus influenza
type b have been important advances in
prevention of pneumonia. Vaccines against
bacteria, such as S. pneumoniae, H. influenza
type b and whooping cough (pertussis) are
highly effective for preventing lower respiratory
tract infections. The influenza vaccine is
effective in preventing influenza. Vaccines
against other viruses, such as measles, are
so effective that they are virtually eliminating
the diseases. Vaccination programmes for
adolescents and adults, which are also
effective, have frequently been neglected.
Conjugate vaccines must be available as part
of expanded programmes for immunisation
in all countries. Development of improved
vaccines with broader coverage is needed to
control or eliminate specific infections.
17
 Antibiotics have made most bacterial
pneumonia curable, although antibiotic-
resistant bacteria can complicate care. As with
other diseases in which the causes are known
and cures are available, key efforts must be
made to improve the availability and delivery
of quality healthcare and effective medicines.
Greater availability of pulse oximeters to
guide supplemental oxygen therapy coupled
with better access to oxygen delivery systems
must be a priority for effective treatment of
severe respiratory infections [26].

Early diagnosis is essential, and includes

the need for heightened awareness in the
community. Better diagnostic tests, including
better sampling procedures and better
methods for the rapid detection of infectious
agents, are needed.

Improved diagnosis enables targeted therapy.

Misuse of antibiotics leads to the emergence
and selection of resistant bacteria. More
intelligent use of antibiotics may decrease
the huge problem of antimicrobial drug
resistance. Physicians worldwide now face
situations in which infected patients cannot be
treated adequately because the responsible
bacterium is totally resistant to available
antibiotics. Strategic areas of intervention
include: 1) prudent use of available antibiotics
in patients and animals, giving them only
when they are needed, with the correct
diagnosis, and in the correct dosage, dose
intervals and duration; 2) hygienic precautions
to control transmission of resistant strains
between persons, including hand hygiene,
screening for carriage of resistant strains and
isolation of positive patients; and 3) research
and development of effective antibiotics with
new mechanisms of action [32].

18 Forum of International Respiratory Societies

Forum of International Respiratory Societies 19
 Tuberculosis
Scope of the disease
In 2015, there were 10.4 million new cases of
TB. Of these, 1 million were children, which
is likely to be an underestimate because the
diagnosis of paediatric TB is challenging.
In 2015, there were an estimated 480,000
new cases of multidrug-resistant TB, and
an additional 100,000 people developed
rifampicin-resistant disease [8]. Among new
cases of TB, 11% of people also had co-
infection with HIV. In 2015, TB killed 1.4
million people, making it the greatest single
infectious agent cause of death and a leading
cause of overall deaths in the world. When
combined with HIV, it killed another 400,000
people [8]. Twenty countries accounted for
84% of the cases of TB [8].
Only recently has TB in children begun to
receive the attention it deserves. Paediatric TB
has been largely ignored because, in general,
children are thought to not spread the disease.
Moreover, TB is difficult to diagnose in young
children because they usually do not produce
sputum. The high susceptibility of infants
and young children to extrapulmonary and
disseminated disease adds to the complexity
of diagnosis. Consequently, diagnostic
approaches for children have lagged.
Likewise, antituberculous drug formulations
have not been developed for paediatric use
until recently.

The incidence of TB is falling at a rate of about

1.5% per year, which is insufficient to end
tuberculosis by the WHO’s stated goal of 2035.
Deaths due to TB decreased 17% between
2005 and 2015, and age-standardised TB
death rates decreased 34% [1]. The treatment
success rate is 83% for drug-sensitive TB,
52% for multidrug-resistant TB and 28% for
extensively drug-resistant TB [8].

The global case-fatality rate remains high at

17%, but varies from less than 5% to more
than 20% [8]. The cost of treating multiple
drug-resistant TB is many times the cost of
treating drug-sensitive disease and strains TB
control programme budgets [33, 34]. About
910,000 persons living with HIV and 87,000
children aged under 5 years began treatment
of latent TB in 2015, but this is only 7% of the
eligible children [8].

20 Forum of International Respiratory Societies

Prevention
In no disease is the phrase “treatment is
prevention” truer than with TB. The factors
promoting the spread of infection relate to
the chance that an uninfected individual is
exposed to a person with infectious TB: the
more cases in the community, the more likely
it is that an individual will become infected.
Factors promoting the development of
disease in infected individuals generally relate
to the function of the immune system. The
most potent factor causing an exposed person
to develop active tuberculosis is infection with
HIV, but other conditions that affect immunity,
such as certain medications and the presence
of poorly controlled diabetes, also increase
the risk of developing active disease.

Inhaling only a few tuberculous bacteria can

result in infection. However, only about one
in 10 people infected with Mycobacterium
tuberculosis will develop active disease,
although the rate is much higher in young
children and people with immunodeficiency
conditions. TB lies dormant because the
infection is contained by the body’s immune
system, but it can become active at any point
in a person’s lifetime. This two-phase sequence
by which the disease develops provides an
opportunity for prevention. By identifying
persons who are proven or are highly likely
to have latent infection and treating those
who have conditions or circumstances that
increase the risk of disease, the likelihood in all healthcare sectors and countries. The
of developing active TB can be substantially long duration of therapy (usually 6 months
reduced. Several drug regimens have been with four drugs in uncomplicated cases)
documented to be effective for treating latent makes adherence to treatment challenging,
tuberculosis [35]. especially in individuals who are taking other
medications for chronic diseases, such as
The current vaccine, Bacille–Calmette–Guérin
HIV infection. Failure to take the full course
(BCG), offers only partial protection against
of prescribed drugs appropriately may
TB but does reduce the risk of disseminated
result in relapse with drug-resistant disease,
TB and tuberculous meningitis in children.
which is more difficult to treat and poses a
Research centres around the world are working
risk to others. For this reason, supervised or
on developing a better vaccine for TB.
directly observed therapy is recommended
as the standard of care to ensure adherence
Treatment throughout the course of treatment.

Most cases of TB can be cured if diagnosed Treatment of patients with multidrug-resistant

early and treated appropriately using
standardised approaches that are based on
evidence derived from clinical trials. The
International Standards for Tuberculosis
Care [36] should be followed by providers
TB is a more complicated issue. Although
the standard has been to treat with five or
six drugs for 14–18 months, a recent trial has
shown a shorter course of therapy is better
[37] and now recommended by WHO.

Forum of International Respiratory Societies 21

 Control and elimination
In May 2014, the World Health Assembly
approved the End TB Strategy, a comprehensive
set of principles and activities developed by
WHO’s Global Tuberculosis Programme over
a 2-year period with broad global consultative
input [38]. The activities within the Strategy are
guided by a set of four overarching principles:
1) government stewardship and accountability
with monitoring and evaluation; 2) strong
coalition with civil society organisations and
communities; 3) protection and promotion
of human rights, ethics and equity; and 4)
adaptation of the strategy and targets at
country level, with global collaboration. The
Strategy provides an overall global framework
for TB control and, ultimately, elimination with
targets of reducing deaths due to TB by 95%
and the incidence of the disease by 90% by
2035, compared with 2015. These principles
convey the responsibilities of government
agencies, while at the same time indicating
the requirement for all health sectors and civil
society to be involved and for services to be
delivered in an equitable manner with respect
for human rights, with implementation of the
strategy at country level [39].

Three main areas of activities (or “pillars”) are

necessary to achieve these targets:

• Pillar 1 Integrated patient care and

prevention
• Pillar 2 Bold policies and supportive
systems
• Pillar 3 Intensified research and innovation

In all pillars, there are activities that represent

new ways of thinking about TB on a global
scale and tend to unify approaches to control
and elimination across low-, middle- and high-
burden countries.

Taken together, the principles and activities

provide a comprehensive globally applicable
approach to TB control and elimination.
Several areas have developed more detailed
and specific plans for TB elimination [38].

22 Forum of International Respiratory Societies

Forum of International Respiratory Societies 23
 Lung cancer
Scope of the disease
Cancer is a major global problem, with about
14.1 million new cases and 8.2 million deaths
in 2012, based on GLOBOCAN estimates [9].
Of the major cancers, lung cancer remains the
most common in the world, with an estimated
1.8 million new cases in 2012. Most (58%) of
these occurred in the less developed regions.
Lung cancer is also the most fatal cancer
globally. In 2012, 1.6 million people died from
lung cancer, accounting for 19.4% of the total
deaths attributable to cancer [9]. The ratio of
mortality to incidence is 0.87. If lung cancer
has spread to other organs, the 5-year survival
is only about 13% [40].
Tobacco smoke causes most cases of lung
cancer by damaging DNA and mutating
protective genes. Lung cancer risks correlate
with the amount and duration of smoking.
Since DNA-damaged genes accumulate over
time, lung cancer may occur years after people
begin or quit smoking. There are now more
former smokers than smokers worldwide, but
former smokers are not free from cancer risk.
Lung cancer can also occur in people who
have never smoked, which is especially
true for Asians. Other risk factors include
passive exposure to tobacco smoke, biomass
fuel, diesel exhaust, radon, asbestos,
and other environmental and workplace
carcinogens. Although asbestos is now
banned from commercial use and production
in most countries, these fibres persist in the
environment, including insulation and fire-
retardant materials inside and on the surface
of many buildings, and remain present in prior
manufacturing sites. Some countries where its
24 Forum of International Respiratory Societies
use is banned still produce and market it to
other countries.
Prevention
Lung cancer is largely preventable through
tobacco control. Public programmes that
reduce smoking are effective, but more are
urgently needed, especially in countries where
smoking is increasing because the incidence
of lung cancer follows increased smoking.
Environmental causes of lung cancer, such as
radon and asbestos, can be monitored and
reduced. Producers of asbestiform materials
should have increased regulations to minimise
or eliminate exports of their carcinogenic
material. Countries must not be allowed to
export asbestos to poorer countries. Other
known modifiable risk factors, such as biomass
fuels, diesel exhaust and air pollution, must
also be addressed. Research is needed to
determine other causes of lung cancer and
how to translate this knowledge into effective
health policy.
Treatment
Care of patients with lung cancer has become
complex and is optimally provided by an
expert multidisciplinary team when available.
In lower-income countries, access to care
and cost-effective treatments can reduce the
human burden and societal impact of lung
cancer.
To guide treatment and to determine
prognosis, lung cancer patients undergo
diagnostic and staging processes. Early-
stage lung cancer is treated with curative-
intent surgery or radiation therapy. Selective
patients may benefit from chemotherapy after
surgical resection, while patients with local
advanced disease may benefit from concurrent
chemo-radiotherapy with or without surgery.
Although advanced stage lung cancer is not
curable, many patients may have symptom
improvement and survival prolongation
by effective treatment. Molecular targeted
therapy against epidermal growth factor
receptor (EGFR) mutations and anaplastic
lymphoma kinase (ALK) re-arrangements
attain tumour response rates of around 70%.
However, cost is a major barrier to these
treatments. Symptom relief and palliative care
must be considered throughout an individual’s
lung cancer journey to provide patient-centred
care. The benefits of treatment must be
balanced against the risks of adverse effects
in individual patients in order to achieve high-
value healthcare.
Access to care remains a major challenge in
lower- and middle-income countries, which
emphasises the global need for affordable,
cost-effective treatments and optimal care.
“Personalised therapy” directed to factors such
as specific mutations may improve the results
of treatment. Such “precision medicine” and
promising immunotherapeutics involve costly
tests and treatments, which are not universally
available.
Identifying and treating early cancer is a
potential lifesaving strategy. A recent large-
scale study showed that screening with CT
Forum of International Respiratory Societies
scans compared to chest radiography resulted
in a 20% reduction in lung cancer-specific
deaths [41]. The use of screening for lung
cancer has been demonstrated, in principle,
in high-income countries, but much cheaper
and more accessible methods are needed for
low-income settings.
Control and elimination
The overarching strategy for elimination of
lung cancer depends on smoking cessation
by helping current smokers to stop, and by
reducing the number of people who start
smoking. Legislation to regulate tobacco
use and its promotion, to eliminate exposure
to cigarette smoke in public areas, and to
raise taxes on tobacco products are proven
techniques that decrease tobacco use. These
efforts are particularly important in countries
where smoking rates are high or rising.
Reducing the risk from other lung carcinogens
such as air pollution, which is now classified as
carcinogenic to humans [42], is needed.
Comparative effectiveness research into
strategies aimed at tobacco use reduction
and cessation through public policy is
needed. Better screening, early diagnosis
and identifying molecular targets for effective
and cost-effective modern treatment should
improve lung cancer outcomes. Globally,
efforts to reduce inequity of care and access
to effective and affordable treatments are
also vital for addressing the lung cancer crisis
around the world.
25
 Other important respiratory
conditions and concerns
In addition to the five respiratory diseases
described, other respiratory conditions also
impact global health. The lungs are the
organ most affected by unhealthy air in the
workplace, and occupational lung disease
is a common health hazard that takes a
huge toll, causing death, disability and
absenteeism. Exposure to asbestos causes
lung fibrosis (asbestosis) and mesothelioma.
Exposure to mineral dusts causes silicosis or
coal worker’s pneumoconiosis, and exposure
to organic antigens causes hypersensitivity
pneumonitis and asthma. These diseases
may be preventable by assuring clean air
in the workplace. Importantly, inhalation of
toxic material both inside and outside the
workplace can cause acute and large-scale
health problems.
Sleep disordered breathing (or sleep
apnoea) is a common condition affecting
1–6% of adults. Sleep apnoea is more common
in older individuals; one study reported
up to 24% of men aged 30–60 years had
obstructive sleep apnoea [43]. Sleep apnoea
causes fragmented sleep and hypoxia, which
has long been recognised to cause daytime
somnolence and increased accidents. More
recently, it has also been associated with
many other illnesses, such as hypertension,
cardiovascular disease, stroke, diabetes,
poor cognitive function and neuropsychiatric
disorders – not to mention effects on
alertness causing problems with safety-
sensitive activities. Furthermore, it appears
to worsen many other illnesses. Paediatric
sleep disorders are increasingly recognised as
causes of morbidity and mortality. Obstructive
sleep apnoea syndrome has been described
in 5% of children tested, but exceeds 10% in
26 Forum of International Respiratory Societies
some paediatric populations. An important
health condition that affects 1% of the world
has great world health significance. The best
preventive measures for sleep apnoea are
maintaining a healthy bodyweight and doing
physical exercise.
Pulmonary hypertension occurs in about
1% of the population in the world and up to
10% of those aged over 65 years. Much of this
is related to left ventricular failure and lung
disease, but schistosomiasis, HIV infection,
rheumatic heart disease and sickle cell disease
are other prominent causes [44]. Treatment
and prevention of pulmonary hypertension
vary depending on the cause and can often
be controlled by alleviating the underlying
conditions.
Pulmonary embolism is a common life-
threatening disease estimated to occur
in 6–20 per 10,000 European inhabitants
annually [16], but the number is likely to be
much higher because both mild and severe
cases go unrecorded and often can be a
diagnostic challenge. Mild cases may be
self-limited and not reported; and end-of-life
cases are usually associated with other severe
diseases, which can be erroneously reported
as the cause of death instead of pulmonary
embolism. Pulmonary embolism is associated
with age, many different health conditions,
genetic predisposition and physical inactivity.
Treatment is generally with anticoagulants.
The respiratory system is in the forefront of
two current global health concerns – climate
change and terrorism. Climate change
affects respiratory diseases by several means.
Temperature is closely associated with air
pollution, which affects many respiratory
conditions. Ozone production increases
with higher temperatures because higher
temperature speeds the reactions of volatile
organic compounds and nitrogen oxides to
produce ozone. Climate change affects the
incidence and severity of respiratory infections
by their affecting vectors and habitats and
changing the transmission patterns of viruses
[45]. Weather events may alter human host
response and susceptibilities to infectious and
non-infectious diseases.
The deliberate use of biological agents
Forum of International Respiratory Societies
or chemicals to inflict casualties has been
outlawed globally since 1925. In 1972, the
United Nations’ Biological and Toxin Weapons
Convention “prohibited the development,
production, accumulation, acquisition, and
retention of biological agents or toxins.”
Unforgivably, they have been used in
conflicts since then. The lungs are particularly
vulnerable to biological or chemical terrorism
because the causative agents are most often
disseminated through the air. Defending
against such attacks requires research to
understand how best to protect the lungs.
27
 What can be done to
combat respiratory disease?
Prevention
The first step for respiratory health is to
prevent illness before it occurs. Identifying and
ameliorating the factors that cause or promote
respiratory diseases can prevent them. Because
respiratory diseases are often linked to the
environment, respiratory conditions are more
preventable than most other system diseases.
The cost of prevention is only a fraction of the
cost of treatment. Preventing and combating
respiratory disease is a highly cost-effective
“best buy” described by the WHO [46].
Prevention starts before birth. In utero and
childhood exposure are major determinants
of chronic adult respiratory disease. Paediatric
factors associated with COPD in adults include
maternal and paternal asthma, maternal
smoking, childhood asthma and severe
respiratory infections [47]. Furthermore,
smoking in the grandmother increases the risk of
asthma in both the mother and grandchild, even
if the mother does not smoke. The deleterious
effects of nicotine and tobacco smoke exposure
are augmented if certain genes’ alleles are
present in either the mother or the foetus [47].
Antenatal and early child exposure to indoor
or outdoor air pollution affect lung growth and
are associated with accelerated lung function
decline later in life [47].
Breathing unhealthy air is a cause or contributor
to most respiratory conditions. The most
common sources of unhealthy air are tobacco
smoke, indoor air pollution from the smoke of
burning fuels, unhealthy air in the workplace,
air pollution from traffic and industrial sources,
and air containing microbes, toxic particles,
fumes or allergens. Improving the quality
28 Forum of International Respiratory Societies
of the air is an important step in promoting
respiratory health.
The best measure to prevent lung disease is to
reduce tobacco use. Smoking was estimated
to be responsible for one in seven deaths in
men and one in 15 deaths in women globally
in 2004 [48]. It is projected that as many as 1
billion people will die from tobacco smoking
in the twenty-first century [49]. Of these
deaths, most will result from cardiovascular
or respiratory disease, including lung cancer
and COPD. In the USA, current smokers are
25 times more likely to die of lung cancer than
those who never smoked [50]. The rate of
death from all causes is three times higher in
smokers than non-smokers and life expectancy
is shortened by 10 years in smokers [51]. In
Europe, the total health cost of tobacco is
about €544 billion annually, which represents
about 5% of the European Union GDP [52].
Passive smoke exposure also leads to
respiratory disease. Since 1964, about
2.5 million non-smokers died from health
problems caused by exposure to second-
hand smoke [53]. In children, second-hand
smoke causes ear infections, asthma attacks,
bronchitis and pneumonia. It increases the
risk for sudden infant death syndrome. Heart
disease and stroke are also increased. An
estimated 34,000 heart disease deaths and
more than 7,300 lung cancer deaths have been
attributed to second-hand smoke annually in
the USA [53].
Intensive educational campaigns in Western
Europe and North and South America have
decreased the number of smokers in many
countries, but the tobacco industry moved its
target to susceptible populations in Eastern
Europe, Asia and Africa to increase sales of
its products. More than 300 million Chinese
smoke more than 2 trillion cigarettes per year
– more than the next four highest tobacco-
consuming nations combined. In China, a
person dies every 30 seconds from tobacco
use [54].
Tobacco smoking is a solvable global problem.
The first international treaty developed for
purposes of health was the WHO’s Framework
Convention on Tobacco Control [55]. The
treaty is an important mechanism by which
governments can control the tobacco industry
by using laws, regulations, administrative
decisions and enforcement measures.
Effective strategies, termed MPOWER [49],
have been developed by the WHO Tobacco-
Free Initiative to support implementation of
the Framework to prevent and reduce smoking
and the demand for tobacco products. Much
more remains to do, particularly in low- and
middle-income countries to mitigate the
pernicious impact of tobacco smoking.
Poor indoor air quality is an important
contributor to respiratory disease. About 50%
of all households in the world and 90% of
rural households use fuels that allow smoke to
be present in the living area, exposing over
2 billion people to noxious smoke [56]. The
WHO estimates that 4.3 million deaths per
year can be attributed to indoor air pollution.
Most disease and death attributable to
exposure to poor indoor air quality occurs in
women and children, especially in low-income
families [57]. Exposure to indoor smoke used
for heating and cooking leads to COPD,
lung cancer and, in children, pneumonia and
asthma [57].
People with lung disease are particularly
susceptible to the effects of outdoor air
pollution. Increased concentrations of
airborne fine particles are associated with
increased hospital admissions and deaths [58].
It is estimated that poor air quality in Europe
leads to an average loss of 8.6 months of life
expectancy [59]. There is a growing body of
evidence that air pollution affects the unborn
child, leading to enhanced susceptibility to
infection, and respiratory and cardiovascular
disease later in life [60]. Children, especially
those with chronic lung disease, are also
more susceptible to the adverse effects of
Forum of International Respiratory Societies
air pollution [61]. The environmental risks are
greater in low- and middle-income countries
and among the disadvantaged and low
socioeconomic sections of society.
Appropriate nutrition and physical activity
are critical for health. Both malnutrition and
obesity contribute to respiratory diseases.
Obesity is linked to obstructive sleep apnoea
in Western societies and to asthma, heart
disease and diabetes. Malnutrition is an
important risk factor for childhood pneumonia
and severe illness.
Prevention of respiratory disease entails
strengthening healthcare systems, using
established guidelines for health promotion
and disease prevention, training medical
personnel and educating the populace.
Treatment and cure
Once disease occurs, the goal is to lessen
its effects and cure it if possible. Reducing
its effects is best accomplished by early
detection, prompt diagnosis and early effective
treatment. Successful treatment is based on
sound medical evidence, is cost-effective and
is generally in accordance with standardised
guidelines. Patients and healthcare workers
can manage diseases better if they are properly
trained and necessary resources are available.
The WHO, FIRS member organisations and
other governmental agencies or respiratory
societies have developed recommendations
for standards of care for specific clinical
conditions. Unfortunately, effective and
uniform implementation, promotion and
adherence to these standards have been
lacking. Great medical breakthroughs are only
significant when they reach the communities
and patients that need them.
In recent decades, medicine has increased
the length and quality of life, although
changing lifestyles, new types of infection
and changing environments have created
new challenges. These advances have
brought costs. Healthcare for those who are
ill or dying is expensive. Increasing healthcare
costs have threatened the financial health
of many nations. On the other hand, work
losses secondary to ill health affect national
productivity. The economic development of
countries is linked to the health of its citizens.
Poor health, both individual and public, along
29
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with lack of education and lack of an enabling
social structure are major impediments to a
country’s development and are the roots of
poverty.
Healthcare delivery can be readily improved
with programmatic research, education, a
trained work force, funding, infrastructure
and an efficient system in which to operate.
Evidence-based guidelines should be
implemented system wide. Specific targeted
national (or regional) interventions should
prioritise interventions that are effective, easy to
implement and monitor, and that target persons
most at risk. For example, in asthma, this could
include a programme with early treatment with
inhaled corticosteroids, reduction in exposure
to tobacco smoke and appropriate education
in the use of inhalers [62].
Economic barriers limit access to care even
in resource-rich settings. Many people simply
cannot afford to obtain good-quality care. In
resource-poor settings, many people do not
seek care from the public health system because
it is lacking, of poor quality or inaccessible.
In many countries, public healthcare systems
are seen as a drain on public funds. They
are vulnerable to abrupt change in funding,
which depends on the political and economic
climate. In some countries, health insurance
systems limit medications and services. Direct
patient costs are greater in resource-poor
countries where up to 90% of the money spent
on healthcare may be paid directly from the
patients to the providers. About 150 million
people experience financial catastrophes from
healthcare costs annually [63]. Governments
may define an essential package of care, but
that care may not be adequate. Restrictions
on healthcare should depend on evidence-
based standards of care.
Disease control and global
reduction or elimination
Controlling and eliminating respiratory
diseases requires optimal use of the current,
effective tools coupled with additional
research. Basic, clinical and public health
research all have important roles in reduction
and elimination of respiratory disease. The
investment in respiratory research has paid
enormous dividends. The rate of pneumonia
and TB is decreasing worldwide [8], as is
Forum of International Respiratory Societies
tobacco use in certain countries. These
successes must stimulate the world to
consolidate and extend these gains to more
countries and more diseases. It cannot be a
short-sighted rationale for reducing effort.
People are living longer and are healthier,
and we are on the threshold of even greater
advances. Many diseases now have genetic
profiles and scientists are working hard
to uncover their basic mechanisms. The
complicated network of cells, signals and
structures is being revealed and used to
identify susceptible individuals, develop
better diagnostic tests and find new
treatments. Equally important is research on
how to apply new research findings to help
people and control disease. The results of
clinical trials are distilled into guidelines on
how best to prevent and manage an illness.
These evidence-based recommendations can
be powerful tools to secure uniform high-
quality medical care throughout the world.
Knowledge created through research is cross-
cultural and enduring, but it must be applied
to be valuable.
In addition to public health measures,
developing healthcare capacity requires
the education and training of clinicians and
researchers. Governments, professional
societies and global governmental and
charitable organisations must act together to
assure the next generation is well equipped to
meet the health needs of the world.
31

Respiratory diseases are an enormous
challenge to life, health and productive human
activity. Prevention, control and cure of these
diseases and promotion of respiratory health
must be a top priority in global decision-
making in the health sector. The control,
prevention and cure of respiratory diseases
are among the most cost-effective health
interventions available – a “best-buy” in the
view of the WHO. Investment in respiratory
health will pay manifold dividends in longevity,
healthy living days and national economies.
Public awareness and control of the
environment are important steps to preventing
respiratory diseases. The key controllable
factors are reduction in tobacco smoking and
improvement in air quality, which includes
reduction in second-hand tobacco smoke,
smoke from indoor fire, and unhealthy public
and workplace air. Strengthening childhood
immunisation programmes and greater
availability of the pneumococcal conjugate
vaccine must be a priority in low-income
countries. Prevention and timely treatment
of HIV infection can have major impact in
reducing the burden of respiratory illness.
Effective training of healthcare workers and
making available medications and appropriate
diagnostics are keys to better lung health.
Summary
improvement in air quality has reduced
deaths and hospitalisations for heart and lung
diseases. Legislation and political action on
clean air makes a difference. The respiratory
societies of the world believe that everyone
has the right to breathe clean air [59] and
we ask lawmakers to enact and enforce
clean air standards in all countries.
Finally, research in respiratory diseases is the
hope for today and the promise for tomorrow.
Research must answer many questions: how do
lung diseases arise, how do they are spread,
who is vulnerable, and what actions can be
used control or cure them, to name a few.
Research must also help us understand what
keeps people healthy. Measures developed
from the research must be cost-effective
and widely applicable. Increased funding to
support respiratory research is needed.

FIRS calls on all governments, communities,

healthcare practitioners and individuals to
promote these effective preventive measures
that have reduced tobacco consumption in
many countries.

The health benefits of clean air policies are

far reaching. Several studies have shown

32 Forum of International Respiratory Societies

 Recommendations
FIRS calls for these essential actions to reduce the burden of respiratory disease and improve
global health:
1. Increase public and policy makers’
awareness that respiratory health
is essential to global health and
that childhood respiratory disease
may have long-term negative
consequences on adult health by
advocating at world health meetings
and through publications and media
postings
2. Reduce, and then eliminate, the
use of all tobacco products through
universal support of the Framework
Convention on Tobacco Control
3. Adopt WHO standards, at a
minimum, to reduce ambient, indoor,
and occupational air pollution for all
countries
4. Promote universal access to quality
healthcare, including the availability of
affordable, quality-assured, essential
medicines and universal coverage for
childhood and adult immunisations,
including new conjugate vaccines
by advocacy through WHO and
government programmes
Forum of International Respiratory Societies
5. Improve early diagnosis of respiratory
diseases through improving awareness
and access to current procedures
and the development of new tools
through world health meetings and
publications
6. Increase education and training of
health professionals in respiratory
disease worldwide though
programmes of the FIRS societies,
WHO and other governmental and
non-governmental organisations
7. Standardise the monitoring of
the prevalence, severity and
management of respiratory diseases
to enable development of well-
informed national strategies
though programmes of WHO and
governmental and non-governmental
organisations
8. Increase respiratory research to
develop programmes, tools and
strategies to better prevent and
treat respiratory diseases though
advocacy for governmental and non-
governmental research organisations
33
 References
1. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-
cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for
the Global Burden of Disease Study 2015. Lancet 2016; 388: 1459–1544.

2. World Health Organization. Global surveillance, prevention and control of chronic respiratory diseases. A
comprehensive approach. Geneva, WHO, 2007. Available from: http://www.who.int/gard/publications/
GARD_Manual/en/

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 Acknowledgements
Writing Committee Contributing Consultants and
Darcy D. Marciniuk, Co-Chair
External Referees
Dean E. Schraufnagel, Co-Chair Innes Asher
Thomas Ferkol Peter Burney
Kwun M. Fong Andrew Bush
Guy Joos Peter Calverley
Victorina López Varela Clayton T. Cowl
Heather Zar Charles Feldman
Paula Fujiwara
Global Initiative for Asthma (GINA) Board
of Directors
Global Initiative for Chronic Obstructive
Lung Disease (GOLD) Board of Directors
Philip Hopewell
Guy Marks
Tony Mok
Helen Reddel
Jonathan Samet

38 Forum of International Respiratory Societies

 About FIRS
Formed in 2001, the Forum of International
Respiratory Societies (FIRS) is composed of
the leading international respiratory societies.
Each society is made up of medical specialists
in respiratory diseases. Their memberships
together have more than 70,000 professionals,
who devote their working lives to some aspect
of respiratory health or disease.
The journals of these societies publish the vast
majority of respiratory scientific breakthroughs
in the world. Their annual meetings provide a
forum for nearly all important research in the
field. Their educational venues teach or train
the majority of respiratory specialists in the
world.
These societies hold meetings at which
individuals with the greatest knowledge
and expertise discuss their latest research
findings. The findings include information
Forum of International Respiratory Societies
about the nature, prevalence, burden, causes,
prevention, control and cure of diseases.
The societies’ expert members develop
statements, guidelines and recommendations
on respiratory topics. These guidelines
influence how healthcare providers everywhere
diagnose, treat and care for their patients with
respiratory problems. The members of these
societies are distributed across the globe and
interact and impact on the lives of many, or
most, people with serious respiratory disease.
The goal of FIRS is to promote respiratory
health worldwide. FIRS speaks with one voice
to communicate the importance of respiratory
health for global health and prosperity. FIRS,
its societies, their members and the patients
they serve, with millions of voices harmonised,
call for action to reduce, prevent, cure and
control the terrible burden of respiratory
disease.
39
 FIRS member societies
Asian Pacific Society of
Respirology (APSR)
The APSR was established in 1986. It is
composed of national societies from the
Asia-Pacific region. Its objectives are the
advancement and promotion of knowledge of
the respiratory system in health and disease.
It promotes and coordinates activities in the
field of respiratory medicine, fosters research
activities in respiratory medicine, organises
and coordinates regular congresses and
meetings. Its publications include the flagship
journal, Respirology, as well as Respirology
Case Reports, APSR Respiratory Updates
and the APSR Newsletter. APSR has many
educational programmes administered
through the ESAP (Educational Seminar of the
APSR) programme. Its scholarships, research
awards and travel awards promote the
careers of young scientists by encouraging
involvement with other researchers in an
international forum.
Website: www.apsresp.org
Headquarters: 2F UK’s Bldg., 2-29-3, Hongo,
Bunkyo-ku, Tokyo 113-0033, Japan
Contact: apsrinfo@theapsr.org (APSR
secretariat office)
Number of Members: 14,520
Publications: Respirology, Respirology Case
Reports, APSR Respiratory Updates, APSR
Bulletin, APSR Newsletter
40 Forum of International Respiratory Societies
Asociación Latinoamericana de
Tórax (ALAT)
ALAT (or the Latin-American Thoracic
Association) was founded in 1996. It
comprises specialists in respiratory medicine
from Latin America, and works closely with the
national medical associations of the region.
ALAT’s mission is to alleviate the suffering of
respiratory disease and promote lung health
through research, knowledge exchange
and continuing medical education. One of
ALAT’s priorities is tuberculosis control, which
remains a prevalent disease in large areas of
Latin America. ALAT promotes development
in the treatment of chest diseases in Latin
America through many activities, including
the publication of its journal (Archivos de
Bronconeumología) in collaboration with
Sociedad Española De Neumología y Cirugía
Torácica (SEPAR). It holds a biennial congress
of specialists in respiratory medicine in
Spanish and Portuguese and supports many
other national and regional events. It offers
training scholarships for young specialists
and continuing medical education courses
for specialists and primary care physicians. It
has developed many manuals and guidelines
for respiratory health professionals in Latin
America.
Website: www.alatorax.org and www.
congresosalat.org
Headquarters: Libertad 2848, 11300
Montevideo, Uruguay
Contact: secretaria.alat@gmail.com (ALAT
Secretary)
Number of members: 2,823
Publication: Archivos de Bronconeumología
American Thoracic Society (ATS)
Created in 1905, ATS is the oldest respiratory
society in the world. Its founding philosophy
“that disease and suffering can be eliminated
faster when discoveries and knowledge are
shared” has been expanded to encompass
all aspects of pulmonary, critical care and
sleep medicine. With its widening mission,
the Society’s membership has become
increasingly diverse, and nearly one-third of
the Society’s members are non-US based. The
mission is to improve health worldwide by
advancing research, clinical care and public
health in respiratory disease, critical illness
and sleep disorders.
ATS publishes three premier journals that
meet the needs of basic, translational and
clinical scientists, produces clinical care
guidelines, advocates for clean air and
tobacco control, works to defeat tuberculosis
in developing countries, and trains
physicians in Latin America, Africa and Asia
to become researchers through its Methods
in Epidemiologic, Operations and Clinical
Research (MECOR) programme. Each year,
the Society also convenes the world’s leading
experts in pulmonary, critical care and sleep
medicine to present and discuss the latest
research in these fields. These meetings have
more than 6,000 original abstracts and more
than 15,000 participants from most countries
in the world.
Website: www.thoracic.org
Headquarters: 25 Broadway, 18th Floor, New
York City, New York 10004, USA
Contact: atsinfo@thoracic.org
Number of Members: 15,000
Publications: American Journal of Respiratory
and Critical Care Medicine, American Journal
of Respiratory Cell and Molecular Biology,
Annals of the American Thoracic Society
CHEST (American College of
Chest Physicians)
Founded in 1935, CHEST champions the
prevention, diagnosis and treatment of chest
diseases through education, communication
and research. By embracing a multidisciplinary
membership from over 100 countries and
Forum of International Respiratory Societies
innovative educational techniques, CHEST is
a global leader in providing clinical education
in pulmonary, critical care and sleep medicine.
CHEST’s premier publication, the journal
CHEST, features outstanding clinical research
and reviews through print, online and mobile
editions. CHEST also publishes CHEST
Physician (a monthly newspaper), CHEST
NewsBrief (a weekly e-newsletter) and CHEST
Today (a daily publication), which offer varied
resources for continuing education and practice
management. Clinicians also know CHEST
for its clinical guidelines in antithrombotics,
cough, lung cancer and more. In addition to its
annual meetings, CHEST provides preparation
for certification or accreditation and live
and e-learning education in pulmonary,
critical care, sleep and paediatric pulmonary
medicine, all designed to enable clinicians to
provide the best care for their patients. The
CHEST Foundation, the charitable foundation
of the American College of Chest Physicians
founded in 1996, champions lung health
by providing support for clinical research,
community service and patient education. By
forming strategic relationships with public and
private sector organisations around the world,
the CHEST Foundation makes an impact on
world health, one community at a time.
Website: http://www.chestnet.org
Headquarters: 2595 Patriot Boulevard,
Glenview, Illinois 60026, USA
Contact: helpteam@chestnet.org
Number of members: 19,000
Publication: CHEST, CHEST Physician, SEEK
European Respiratory Society
(ERS)
ERS is an international organisation that brings
together physicians, healthcare professionals,
scientists and other experts working in
respiratory medicine. ERS is one of the leading
medical organisations in the respiratory field,
with a growing membership representing over
140 countries worldwide.
The ERS mission is to promote lung health
in order to alleviate suffering from disease
and drive standards for respiratory medicine
globally. Science, education and advocacy
are at the core of everything ERS does. ERS
41
 is involved in promoting scientific research
and driving standards through the training of
respiratory professionals. It also plays a key
role in education and in advocacy – raising
awareness of lung disease amongst the public
and politicians.
Website: www.ersnet.org
Headquarters: European Respiratory Society,
4 Avenue St-Luce, 1003 Lausanne, Switzerland
Contact: info@ersnet.org
Number of Members: 36,000
Publications: European Respiratory Journal,
ERJ Open Research, European Respiratory
Review, ERS Monograph, Breathe, ERS
Handbooks, European Lung White Book
Pan African Thoracic Society
(PATS)
The Pan African Thoracic Society (PATS) was
formed in 2003 to create a representative
African respiratory society for the region and
to address the high burden of respiratory
illness in Africa, and members originate from
33 different African countries. The overall aim
of PATS is to promote lung health in Africa
through education, training, research and
advocacy. PATS has developed several sentinel
activities to achieve its aims. The Pan African
Thoracic Society programme in Methods
in Epidemiologic, Clinical and Operations
Research (PATS-MECOR) began in 2007 with
the aim of developing research capacity in
Africa. Highly successful courses have been
held annually for trainees from several African
countries. The African Journal of Respiratory
Medicine (AJRM) is closely linked with PATS,
including a PATS-elected editorial board.
Website: www.africanthoracic.org
Headquarters: Virtual society
Contact: www.africanthoracic.org
Number of members: 720
Publication: African Journal of Respiratory
Medicine
42 Forum of International Respiratory Societies
The Union (International Union
Against Tuberculosis and Lung
Disease)
Since its founding as a global scientific
organisation in 1920, The Union has drawn
from the best evidence and the skills,
expertise and reach of its members, staff and
consultants to advance solutions for the most
pressing public health challenges affecting
people living in poverty. The Union works
with stakeholders across the globe from every
sector, including governments, international
agencies, civil society and the private sector.
Its annual World Conference on Lung Health
attracts upwards of 4,000 delegates and the
organisation is currently developing solutions
for tuberculosis, HIV and other lung diseases,
and policies to reduce tobacco use and
prevent non-communicable diseases. With
more than 20,000 members and publication
subscribers from 146 countries, The Union
has its headquarters in Paris and 10 offices
worldwide in Africa, the Asia Pacific region,
Europe, Latin America, North America, and
South East Asia.
Website: www.theunion.org
Headquarters: 68, boulevard Saint-Michel,
75006, Paris, France
Contact: www.theunion.org/contact
Number of Members: 20,000
Publications: The International Journal of
Tuberculosis and Lung Disease, Public Health
Action, and many technical manuals and other
educational and scientific works